Cse Report Journl of Orthopedic Cse Reports 2017 My-Jun: 7(3):71-75 The Reversed Less Invsive Stilistion System-Distl Femur Technique: Appliction in n Adult Ptient with Osteogenesis Imperfect Sustining Femorl Frcture Mrkus S Hnke 1, Mrius Johnn Keel 1, Ing A Todorski 1, Johnnes Dominik Bstin 1 Wht to Lern From this Article? The reversed less invsive stilistion system-distl femur technique should e considered s slvge procedure in rre cses such s in osteogenesis imperfect whenever intrmedullry niling is difficult. Astrct Introduction: The im of this study ws to report the surgicl mngement nd to discuss the options for frcture fixtion in n dult ptient with osteogenesis imperfect (OI) who sustined trochnteric femorl frcture fter simple fll from stnding position. Cse Report: As result of multiple frctures during childhood, this dult ptient with OI presented with short stture. The rdiogrphs reveled displced, intertrochnteric frcture with sutrochnteric extension of the left femur. The intrmedullry cnl ws nrrow, the femur presented with severe owing deformity, nd the one qulity ws poor. The implnt of choice ws plting using the reversed less invsive stilistion system-distl femur (LISS-DF) technique. This technique ws introduced for the mngement of sutrochnteric frctures in the elderly with poor one stock. In ddition, locking plte ttched to the LISS-DF llowed for dditionl screw plcement t the pex of the curvture of the femur lthough the plte ws not in line with the femur t this site. Cerclges were used for metphysel reduction nd fixtion. 4-month postopertively, the ptient ws multory without ny ssistnce with full weight ering. At the ltest follow-up 1-yer postopertively, the ptient ws still free of complints nd t her preinjury ctivity level. Conclusion: The presented technique ws successful s slvge procedure in rre cse of dult OI presenting with femorl frcture with chrcteristics influencing the decision-mking in tretment options. Keywords: Femur, frcture, osteogenesis imperfect, reversed, less invsive stilistion system-distl femur. Introduction Surgicl tretment with open reduction nd fixtion of displced trochnteric femur frctures in dult ptients with osteogenesis imperfect (OI) is chllenging. Intrmedullry niling in the presence of femorl owing deformity is demnding; three-dimensionl correction of the lignment might ecome necessry to llow for nil insertion while potentil chnges of soft-tissue restrins hve to e considered s well. In ddition, the use of pltes insted of intrmedullry nils might e questionle s the shpe of the plte might not fit the deformed lignment of the femur nd the poor implnt nchorge in the wek one Author s Photo Gllery Access this rticle online Wesite: www.jocr.co.in Dr. Mrkus S Hnke Prof. Dr. Mrius Johnn Keel Dr. Ing A Todorski PD Dr. Johnnes Dominik Bstin DOI: 2250-0685.812 1 Deprtment of Orthopedic nd Trum Surgery, University of Bern, Inselspitl, Bern, Switzerlnd. 71 Address of Correspondence PD Dr. Johnnes Dominik Bstin, Deprtment of Orthopedic nd Trum Surgery, University of Bern, Inselspitl, Freiurgstrsse 3, 3010 Bern, Switzerlnd. E-mil: johnnes.stin@insel.ch Journl of Orthopedic Cse Reports pissn 2250-0685 eissn 2321-3817 Aville on www.jocr.co.in doi: 10.13107/jocr.2250-0685.812 This is n Open Access rticle distriuted under the terms of the Cretive Commons Attriution Non-Commercil License (http://cretivecommons.org/licenses/y-nc/3.0) which permits unrestricted non-commercil use, distriution, nd reproduction in ny medium, provided the originl work is properly cited.
might result in filure. We present cse of displced nd comminuted trochnteric frcture in n dult ptient with OI presenting with poor one stock which ws treted successfully y the reversed less invsive stilistion system-distl femur (LISS-DF) technique. www.jocr.co.in Cse Report A 29-yer-old femle South Americn tourist with known OI ws dmitted to our emergency deprtment fter stumle fll on her left side. According to the typicl presenttion of her sic disese, n nterolterl owing of the left femur ws present efore the injury, wheres correction osteotomy ws performed erlier on her right femur in South Americ (Fig. 1). She reported out forty frctures nd more thn thirty surgicl tretments since irth. The ptient is of short stture with 1.24 m. On presenttion, the ptient ws conscious, orientted, hemodynmiclly stle, nd complined mssive pin on her left hip nd femur. The left lower lim presented with shortening nd mlpositioning in distinct externl rottion. The dignostic workup reveled n intertrochnteric frcture with sutrochnteric extension of the left femur (Fig. 2) with severe owing deformity (Fig. 3). An initil closed reduction of the distinct disloction of the frcture under nlgosedtion ws performed. Then, the frcture ws treted with LISS-DF (LISS for the distl femur, DePuy Synthes, Zuchwil, Switzerlnd) in reversed contrlterl ppliction (Fig. 4) [1]. The ptient ws plced in the lterl decuitus position, nd suvstus pproch to the left femur ws performed. Frcture reposition ws chieved with xil trction, rottion, nd k-wire s joystick in the proximl trochnteric frgment. Preliminry reposition ws chieved using cerclges. The insertion of the LISS-DF in reversed contrlterl ppliction ws performed fter preending of the proximl plte in slight vlgus direction to mtch the ptient ntomy. A preliminry k-wire fixtion nd fluoroscopic control followed y screw fixtion of the plte were performed. Furthermore, impction grfting of the proximl metphysel frcture comminution with llogrft ws crried out. To limit the length of the ridging osteosynthesis, locking ttchment plte ws used. This plte fcilitted dditionl screw plcement t the pex of the curvture of the femur lthough the plte ws not in line with the femur t this site (Fig. 5). The post-opertive regimen consisted of non-weight ering moiliztion for 8 weeks with crutches. Clinicl nd rdiogrphic follow-up showed no displcement with consolidtion of the frcture fter 8 weeks (Fig. 5). Hence, the ptient ws llowed to progress with prtil weight ering for 4 weeks, followed y full weight ering. The ptient ws followed up for 12 months nd presented lredy fter 5 months with physicl sttus comprle to the pre-opertive level without ny limittions (Fig. 6, 7, 8). Discussion In generl, intrmedullry fixtion is recommended for the tretment of long one frctures in OI [2]. However, in long ones, the intrmedullry dimeter remins smll so tht only nils with smll dimeters re pplicle, eing t risk for nonunion due to indequte stility [2]. Accordingly, non-union ws noted in 24% of frctures nd 52% of osteotomies [3]. In ddition, proximl femorl frctures re difficult to nil in ptients with short skeleton nd severely owed or deformed femurs [4]. Elstic stle intrmedullry niling (ESIN) might e nother option for intrmedullry osteosynthesis; however, significntly higher compliction rte nd four times higher compliction rte in lengthunstle frctures (comminution frctures) for ESIN compred to plte Figure 1: Conventionl rdiogrphs of the pelvis with n nteroposterior view presenting the ntomy of the left femur t the preinjury level when the ptient ws 10 yers old nd hve hd some intrmedullry niling of the right femur to correct deformity. Figure 2: Conventionl rdiogrphs presenting the () nteroposterior nd () xil views of the femur in 29-yer-old femle with known osteogenesis imperfect who sustined intertrochnteric femur frcture with sutrochnteric extension following simple fll from stnding position. osteosynthesis were reported, with the most common compliction frcture mllignment t the time of rdiogrphic union [5]. Sink et l. [6] reported in concordnce to Li et l. higher compliction rtes in lengthunstle frctures nd limited the use of ESIN in these frctures. Our ptient presented with comminuted frcture with posterolterl frgment, nd due to the rther high compliction rte in unstle frctures, ESIN ws not considered s n osteosynthesis of choice. Due to the comminution, the nrrow femorl cnl, the severe femorl owing, nd the ove mentioned concerns with intrmedullry niling our tretment of choice were plting using locking compression plte 72 Journl of Orthopedic Cse Reports Volume 7 Issue 3 My - Jun 2017 Pge 71-75
Figure 3: The lignment of the femur is presented y three dimensionl reconstructions with () nteroposterior nd () lterl views of the frctured left femur fter simulted reduction. A severe nterior owing of the femur is present. Figure 5: Conventionl rdiogrphs presenting the () nteroposterior nd () xil views of the left femur 2-month postopertively. 73 Figure 4: Conventionl rdiogrphs presenting the femur with () nteroposterior nd () xil views fter open reduction nd internl fixtion y the reversed less invsive stilistion system-distl femur technique. (LCP) without correction of the deformity. The rtionle for using LCP ws s follows: OI leds to impired one qulity comprle to osteoporotic one. Compred to conventionl plte constructs, locking plte constructs hve mechnicl dvntges, nd in osteoporotic one, these re of prticulr enefit [7, 8]. Besides n incresed implnt nchorge in the wek one, the LCP should ct s ridging osteosynthesis like n internl fixtor iming on reltive stility to llow for secondry frcture heling. Due to the short stture of the ptient, locking compression peditric hip plte might e considered. However, our ptient presented with sutrochnteric Figure 6: Conventionl rdiogrphs presenting the () nteroposterior nd () xil views of the left femur 5-month postopertively. extension of the intertrochnteric frcture preventing the use of the reltively short peditric LCP for the lck of stle fixtion. However, long proximl femorl LCP might e unsuitle s well s due to its lck of nterior curvture nd limited options ville for screw insertion [9]. Therefore, the reversed LISS-DF technique ws used for the following resons: This plte nd technique (1) offers multiple options of fixtion nd is curved mtching the nterior curvture of the femur [1, 10, 11], (2) is le to er more xil lod compred to the stndrd proximl femorl compression plte offers thus iomechnicl dvntge [12], (3) provides plte hed consisting of five-threded 5.0mm peripherl screw holes ccepting locking screws enling the surgeon to insert two rows of long locking screws up to the femorl clcr to chieve sufficient stility [10, 11], nd (4) is effective in voiding cox vr deformity nd the use is recommended in ptients with severe osteoporosis [13]. The reversed LISS-DF technique showed promising results in iomechnicl tests for complex, unstle trochnteric frctures in the Journl of Orthopedic Cse Reports Volume 7 Issue 3 My - Jun 2017 Pge 71-75
Figure 7: Conventionl rdiogrphs presenting the () nteroposterior nd () xil views of the left femur 1-yer postopertively. Figure 8: Clinicl photogrphs showing the ptient 4-month postopertively free of complints during either () single-leg stnce or () squt stnce. elderly or s slvge procedure [14, 15]. In clinicl studies, Acklin et l. [1] recommended the use s possile lterntive in young ptients with multifrgmentry proximl femorl frctures. M et l. [4] recommended the use s n option for frctures tht re expected to e difficult to nil. Hn et l. [13] recommended the use in ptients with severe osteoporosis. Gogn et l. [11] reported promising results in fixtion of sutrochnteric frctures. Moreover, this technique ws used for successful revision in ptients with nonunion of proximl femorl frctures including sutrochnteric frctures fter filed intrmedullry niling [10]. Conclusion The reversed LISS-DF technique ws the tretment option of choice nd successful in the mngement of comminuted femur frcture in n osteoporotic one in our dult ptient suffering from OI with specific ntomic conditions, nmely, pronounced owing of the femur, short skeleton, nd nrrow endomedullry femorl cnl s n lterntive to intrmedullry niling. Clinicl Messge The reversed LISS-DF technique ws successfully used s slvge procedure in rre cse of dult OI presenting with comminuted frcture in proximl femur poor one qulity nd pre-existing owing deformity nd nrrow intrmedullry cnl in ptient with short stture. References 1. Acklin YP, Bereiter H, Sommer C. Reversed LISS-DF in selected cses of complex proximl femur frctures. Injury 2010;41(4):427-429. 2. Cho TJ, Lee K, Oh CW, Prk MS, Yoo WJ, Choi IH. Locking plte plcement with unicorticl screw fixtion djunctive to intrmedullry rodding in long ones of ptients with osteogenesis imperfect. J Bone Joint Surg Am 2015;97(9):733-737. 3. Munns CF, Ruch F, Zeitlin L, Fssier F, Glorieux FH. Delyed osteotomy ut not frcture heling in peditric Osteogenesis imperfect ptients receiving pmidronte. J Bone Miner Res 2004;19(11):1779-1786. 4. M CH, Tu YK, Yu SW, Yen CY, Yeh JH, Wu CH. Reverse LISS pltes for unstle proximl femorl frctures. Injury 2010;41(8):827-833. 5. Li Y, Heyworth BE, Glotzecker M, Seeley M, Suppn CA, Ggnier J, et l. Comprison of titnium elstic nil nd plte fixtion of peditric sutrochnteric femur frctures. J Peditr Orthop 2013;33(3):232-238. 6. Sink EL, Fro F, Polousky J, Flynn K, Grll J. Decresed complictions of peditric femur frctures with chnge in mngement. J Peditr Orthop 2010;30(7):633-637. 7. Mirnd MA. Locking plte technology nd its role in osteoporotic frctures. Injury 2007;38 Suppl 3:S35-S39. 8. Cornell CN, Aylon O. Evidence for success with locking pltes for frgility frctures. HSS J 2011;7(2):164-169. 9. Ptil SS, Krkmkr SS, Ptil VS, Ptil SS, Rnwre AS. Reverse distl femorl locking compression plte slvge option in non-union of proximl femorl frctures. Indin J Orthop 2016;50(4):374-378. 10. Vishy R, Agrwl AK, Gupt N, Vijy V. Reversed distl femorl locking plte for filed proximl femorl nil with non-union of proximl femorl frctures. Int Orthop 2016;40(8):1709-1715. 11. Gogn P, Mukhopdhyy R, Singh A, Devgn A, Aror S, Btr A, et l. Contrlterl reversed distl femorl locking plte for fixtion of sutrochnteric femorl frctures. Chin J Trumtol 2015;18(5):279-283. 12. McLen SB, Evns S, O Hr JN. A comprison of reversed locking compression-distl femorl pltes nd lde pltes in osteotomies for young dult hip pthology. Hip Int 2013;23(6):565-569. 74 Journl of Orthopedic Cse Reports Volume 7 Issue 3 My - Jun 2017 Pge 71-75
13. Hn N, Sun GX, Li ZC, Li GF, Lu QY, Hn QH, et l. Comprison of proximl femorl nil nti-rottion lde nd reverse less invsive stiliztion system-distl femur systems in the tretment of proximl femorl frctures. Orthop Surg 2011;3(1):7-13. 14. Chen Y, Liu S, Lin P, Wng Y, Wng J, To J, et l. Comprtive iomechnicl study of reversed less invsive stiliztion system nd proximl femorl nil ntirottion for unstle intertrochnteric frctures. Chin Med J (Engl) 2014;127(23):4124-4129. 15. Konstntinidis L, Huschild O, Beckmnn NA, Hirschmüller A, Südkmp NP, Helwig P. Tretment of periprosthetic femorl frctures with two different miniml invsive ngle-stle pltes: Biomechnicl comprison studies on cdveric ones. Injury 2010;41(12):1256-1261. Conflict of Interest: Nil Source of Support: None How to Cite this Article Hnke MS, Keel MJ, Todorski IA, Bstin JD. The Reversed Less Invsive stilistion System-Distl Femur Technique: Appliction in n Adult Ptient with Osteogenesis Imperfect Sustining Femorl Frcture. Journl of Orthopedic Cse Reports 2017 My-Jun;7(3):71-75. 75 Journl of Orthopedic Cse Reports Volume 7 Issue 3 My - Jun 2017 Pge 71-75